Psychotic Disorders; Schizophrenia, Schizophreniform Disorder, Delusional Disorder, Brief Psychotic Disorder, Schizoaffective Disorder.
Psychosis: Hallucinations Auditory, visual, tactile, olfactory (smell). Auditory is most common. Delusions-Themes: Persecution, grandeur, sin,
illness, destruction. Types: Somatic, erotomaniac, nihilistic, referential, grandiose. Positive and Negative Psychotic Symptoms-Disorganized
thinking (inferred from speech): Formal thought disorder, Tangentiality, Circumstantiality, Loose associations, Neologisms (made up words),
“Word-salad”/ Negative Symptoms-Avolition (lack/decline in motivation), Diminished emotional expression, Blunted or flat affect, Anhedonia,
Asociality, Alogia (‘poverty of speech’). Catatonia: A state of unresponsiveness, psycho-motor immobility or behavioral abnormality while the
person is awake. Catatonic stupor: no psychomotor activity or responsiveness to environment. Catalepsy: rigid uncomfortable postures held
against gravity. Waxy Flexibility: Negativism: opposition or lack of responsiveness to instructions or external stimuli. Mutism: verbally minimally
responsive. Schizophrenia: Characteristic symptoms: Two or more of the following (1 from first 3), each present for much of the time during a
one-month period: Delusions, Hallucinations, and/or Disorganized speech, Grossly disorganized or catatonic behavior. Negative symptoms:
Blunted affect, alogia, or avolition. Social/occupational dysfunction. Duration: Continuous signs of the disturbance persist for at least six
months. This six-month period must include at least one month of symptoms. *The speech disorganization criterion is only met if it is severe
enough to substantially impair communication. **Ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in any
form of goal-directed behavior, leading to difficulties in performing activities of daily living. Episodic Cycle of SZ: Premorbid stage: prior to onset
of illness. Prodromal stage: deterioration in personal functioning. - Nathaniel Ayers. Acute phase: positive symptoms. Residual: remaining
negative symptoms. Subtypes (no longer used in DSM) Paranoid type: Where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent- Most common. Disorganized type: Where thought disorder and flat affect are
present together. Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include
catatonic stupor and waxy flexibility. Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or
catatonic types have not been met. Residual type: Where positive symptoms are present at a low intensity only. Removed because of limited
diagnostic stability, poor validity. Also, no distinctive treatment response for each subtype (i.e., not clinically useful). Schizoaffective Disorder:
An uninterrupted period of illness during which there is a major mood episode (mania or depression) at the same time as psychotic symptoms.
Delusions or hallucinations for 2 weeks or more in the absence of a major mood episode during the lifetime of the illness. Mood symptoms are
present for the majority of the total duration of the illness. Delusional disorder- The presence of 1+ delusions with a duration of 1 month or
longer. Criterion A for schizophrenia has never been met. Hallucinations, if present, are not prominent and are related to the delusional theme.
Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. Subtypes:
Erotomanic: person strongly believes that another individual is in love with him or her. Grandiose, Jealous, Persecutory. Somatic: false beliefs
that one's bodily function or appearance is grossly abnormal. Mixed/Unspecified. Brief psychotic disorder-Presence of one (or more) of the
following symptoms. At least one of these must be (1), (2), or (3): Delusions, Hallucinations. Disorganized speech (e.g., frequent derailment or
incoherence). Grossly disorganized or catatonic behavior. Note: Do not include a symptom if it is a culturally sanctioned response. Duration of
disturbance is minimum 1 day, but less than 1 month, with eventual full return to premorbid level of functioning. Schizotypal Personality
Disorder- Being a loner and lacking close friends outside of the immediate family./ Flat emotions or limited or inappropriate emotional
responses. /Persistent and excessive social anxiety /Incorrect interpretation of events, such as a feeling that something that is actually harmless
or inoffensive has a direct personal meaning/ Peculiar, eccentric or unusual thinking, beliefs or mannerisms/ Suspicious or paranoid thoughts
and constant doubts about the loyalty of others /Belief in special powers, such as mental telepathy or superstitions/ Unusual perceptions, such
as sensing an absent person's presence or having illusions/ Dressing in peculiar ways, such as appearing unkempt or wearing oddly matched
clothes/ Peculiar style of speech, such as vague or unusual patterns of speaking, or rambling oddly during conversations/ Differences between
SZ and SZPD: Ability for reality testing remains intact, more open to corrective/rational feedback. If psychotic symptoms occur, much less
frequent and intense than in SZ. Epidemiology (STATS SCHIZOPHRENIA) - Worldwide prevalence: .55-1.5%, More common in urban areas.
Diagnosed 1.4x more in men. Stress-related onset, Downward economic spiral. Onset: Earlier in men (20-28) than women (26-32), Crosscultural prevalence rates vary, More commonly diagnosed in African Americans in the US compared to Euro/White Americans, also
disproportionally diagnosed in Latino-Am/Hispanic. Associated Features: Cognitive/communication symptoms- Loose associations, Neologisms:
"I'm going to the park to ride the wallywhoop.", Clang speech: "Deck the halls with boughs of holly, folly, polly, dolly, hello Dolly, want a
lollipop?", “Word Salad”: "Give paper floor me school hop bus.”, Echolalia: repeating words of others. Thought
broadcasting/insertion/withdrawal. Interpersonal Isolation. Suicidality: 12% complete suicide, 20-40% attempt suicide, More frequent
remission = more likely suicide attempt. High comorbid depression and anxiety; 40% comorbid substance abuse. Preceded by a prodromal
period:, Predicted from toddler-age videos: less responsiveness, eye contact, positive affect, Neurological soft signs: poorer fine and, gross
motor coordination, Brain abnormalities suggest longs-standing structural impairment. SZ and SES: In industrialized countries, SZ is less
prevalent in hi SES populations, more prevalence in lower SES. Social Selection (Downward drift): illness causes people to drift down the SES
spectrum due to competitive disadvantage. Social Causation: being poor brings more stress, leads to higher prevalence of illness in lower
classes. Prognosis for Psychotic Disorders: Life expectancy is 10-12 years shorter than average, Negative symptoms may lead to greater
functional impairment than positive symptoms. Recovery rate of about 14% in first five years; treatment response in first two years predicts
recovery later. Most likely to recover if: Female, Rapid (acute) onset, Later onset, “Resilient”, Mainly positive symptoms. Positive Prognostic
features: Identifiable incidence associated as trigger/ Acute onset (vs. insidious)/ Late onset / Being female*/ No negative symptoms / Longer
spaces between relapses / Good premorbid functioning/ *Late-onset SZ more common amongst females, they often have more affective and
positive symptoms, fewer negative symptoms and cognitive deficits, and better course of illness with less impairment. Myths about
psychosis/SZ: Ppl w SZ much more likely to be on receiving end of violence (33-37% in past year; Goodman 2001), and to self-harm (48%, De
Heurt 2000) than to aggress others (Fazel: 1/300 murder). Excess risk appears to be mediated by substance abuse comorbidity, and similar to
those w substance abuse w/o psychosis (Fazel, 2009). Theories Explaining Psychosis: biology in schizophrenia - Most consistent finding:
enlarged ventricles and smaller brain size/ Reduced mylination and connectivity (Konrad)/ Genetics: 48% in MZ twins, compared to 17% in DZ
twins (Gottesman, 1991)/ More recent studies show lower concordance rates (60% in 1960’s, 15% 1990’s.)/ Stress-Diathesis model: Genetics +
Stressors = Schizophrenia. Synaptic Pruning: excessive in schizophrenia. Treatment for Schizophrenia: Skills Training Effective for daily living, but
less effective for other symptoms.
Personality Disorders - Integrated collection of traits / Adaptation to life (biology & environment) / Learned rituals/practices/beliefs, etc. of a
culture, that have been filtered and shaped by: Biological predisposition/temperament / Mechanisms of cultural transmission: Family, Peer
groups, Racial, gender, religious membership, etc. (i.e., community), SES/class. DSM-5 model of personality disorders- A personality disorder
reflects adaptive failure of four components of personality functioning: Impaired sense of self, as defined by both Identity and Self-directedness
/ Interpersonal impairments consisting of impairment in capacity for Empathy and Intimacy. These 4 areas are measured on a scale of 0-4
(healthy functioning to extreme impairment). PDs are stable, chronic, continuing patterns of behavior and beliefs. Personality is extreme, rigid,
pervasive, has early onset in teens/early adulthood, behavior is not socially acceptable. Consists of traits, not symptoms or episodes Are egosyntonic (vs. ego-dystonic mood disorders). Why do people have PDs - Psychodynamic explanations - Childhood factors: Humiliation, criticism,
ridicule, intrusiveness, role inversions, overlooking of needs, denial of reality / These experiences create maladaptive relational/attachment
schemas / Leads to maladaptive defenses: projection, splitting, omnipotent control, etc. Cognitive-Behavioral - Environment shapes and
reinforces behavior. Evolutionary: PDs are combinations of traits (in the same manner of combinations of genes) that are largely maladaptive in
the context of contemporary society, but at some point or in some situation have adaptive value. Cluster A: Odd/eccentric - Cluster B:
Dramatic, emotional, erratic, harmful - Cluster C: Anxious/fearful. Cluster A Paranoid: extreme distrust/suspiciousness, Schizoid: detached
socially, restricted emotional expression, Schizotypal: Eccentric behavior, cognitive or perceptual distortions (ideas of reference, magical
thinking), acute discomfort in relationships. Paranoid PD - Four or more of the following: Suspects, without basis, that others are exploiting,
harming or deceiving / Preoccupied with unjustified doubts about loyalty and trustworthiness / Reluctant to confide in others because of fear
that the information will be used against them/ Reads hidden meaning into benign remarks / Bears grudges / Perceives attacks on character or
reputation that are not apparent to others/ Recurrent suspicions regarding fidelity. Prevalence, etc. Differential diagnosis: Schizophrenia,
Antisocial PD, 2.3-4.4% of population / In clinical settings, more frequently male. Schizoid PD - Four or more: Neither desires nor enjoys close
relationships / Almost always chooses solitary activities / Little interest in sexual experiences with another person / Takes pleasure in few, if
any, activities / Lacks close friends or confidants / Appears indifferent to praise or criticism / Shows emotional coldness, detachment, or flat
affect. Prevalence, etc. 3.1-4.9% prevalence, Given to daydreaming, fantasy / In childhood, could be ‘loners,’ bullied / Unlikely to show up in
treatment, poorly studied / Apparent sexual detachment- speculative / Can seem aloof/sense of superiority / Should this be a disorder?
Associated Features Introversion / Over-valuing internal life/intellect / Differential Dx: Autism, asperger’s., Alexithymia, Depression/anhedonia,
Dissociative? “far away,” “not aware,” “miles away,” or “remote” / Identity, reality testing, defense / Arrogance and superiority. Schizotypal PD
-Five or more of the following: The feeling that events have a peculiar and unusual self-referential meaning / Odd beliefs/magical thinking
(clairvoyance) / Unusual perceptual experiences, including bodily illusions / Odd thoughts and speech / Suspiciousness and paranoid ideas /
Inappropriate affect / Odd, eccentric or peculiar behavior or appearance / Lack of close friends / Excessive social anxiety that does not diminish
with familiarity and is associated with paranoid fears. Associated features - The social isolation in Cluster A PDs that result from acute social
discomfort acts to limit the opportunities for corrective social experiences, thus further removing emotional and cognitive functioning from
social control - Tx: antypsychotics and SSRI’s can be helpful / Schizotypal PD shares common genetic and neurobiological substrates with
schizophrenia. Paranoid PD vs Schizoids/Schizotypal: With Schizoids/Schizotypal, beliefs and assumptions over-rule incoming info. Paranoid:
capable of discerning discrepancy between their beliefs and reality but try to reframe the conflicting info and manipulate other's behavior to be
more consistent w their conceptions. This is done through projection, denial, projective identification, avoidance, etc. Schizoids/Schizotypal less
aware of conflicting info and appear even more detached from reality. Many of their needs are met thru fantasy, magical thinking, and
sometimes delusions. The Disorders: Cluster B: Antisocial: disregard for and violation of rights of others/ Histrionic: Excessive, superficial
emotionality and attention-seeking / Borderline: instable interpersonal relationships, self image and emotions; impulsive and self-destructive
behavior / Narcissistic: Grandiosity, need for admiration, lack of empathy. Antisocial PD - Three or more: Failure to conform with social norms
w.r.t. lawful behavior / Deceitfulness, as indicated by repeated lying, use of aliases, conning others for profit or pleasure. / Impulsivity or failure
to plan ahead / Irritability or aggressiveness, as indicated by physical fights or assaults / Reckless disregard for safety of self or others /
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or to honor financial obligations / Lack of
remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another person. / The individual is at least
age 18 years. / There is evidence of conduct disorder with onset before age 15 years. / Note: not the same as the vernacular “antisocial”;
synonyms are psychopath and sociopath. Prevalence, etc. Not always criminal! But found in ½ of male prisoners and ¼ of female prisoners /
Disproportionately male / Associated with substance abuse / Reduced autonomic responses to stimuli associated with other’s distress and sad
expressions / Some evidence of psychopathy-related amygdala dysfunction during emotional memory (Kiehl 2001) / Over-activation of
(pre)frontal regions, which in turn, inhibits amygdala reactivity (Larsson 2013). Empathy vs sympathy / Cognitive vs. emotional empathy, Theory
of Mind. Causes/correlates: Arousal and avoidance learning: Psychopaths show lower level of arousal, which might explain their engaging in
more stimulating activity to have optimal arousal. / Psychopaths didn't learn from shocks are quickly as controls, less sensitive to pain (Lykken)
/ Method of reinforcement - Sociopaths functioned better using money as reinforcement, rather than pain (Schmauk). Narcissistic PD - Five or
more: Grandiose sense of self importance / Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love / Believes
that he or she is special and can only be appreciated in special places/by special people / Requires excessive admiration / Has a sense of
entitlement / Is interpersonally exploitative; takes advantage of others / Lacks empathy; is unwilling to recognize or identify with the feelings
and needs of others / Is envious of others or believes others are envious of them / Arrogant, haughty behaviors or attitudes. Prevalence, etc. 1% of general population, 2-15% of outpatients/ More often in men / On an uptrend in the US / Significant impairments in emotional empathy,
but little to no impairment in cognitive empathy / High in explicit and implicit shame / Deficits in recognition of emotion when viewing facial
expressions (Marissen 2012), in empathic concern, and mirroring emotions when viewing emotionally charged situations. Borderline
Personality Disorder (BPD) - Frantic efforts to avoid real/imagined abandonment. / Recurrent unstable/intense relationships characterized by
extremes of idealization and devaluation. / Unstable self-image or sense of self. / Impulsivity in 2+ areas that are potentially self-damaging
(e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving) / Recurrent suicidal behavior, gestures, threats or selfinjuring behavior / Affective instability / Chronic feelings of emptiness / Inappropriate anger or difficulty controlling anger/ Transient, stressrelated paranoia, delusions or severe dissociative symptoms. BPD Stats - Lifetime prevalence: 1-2% / Chronic, but “mellows” with time. /
Significant gender gap: 3:1 female / Strong link to early life trauma, particularly sexual abuse/ Accounts for 1/5 of psychiatric hospitalizations /
Treatment: Dialectical Behavior Therapy (DBT) by Linehan / Emotion regulation accounts for tx success of self-harming behavior in BPD /
Neuroimaging in BPD: Limbic hyperreactivity and diminished recruitment of frontal brain regions. Histrionic PD : Five or more: Uncomfortable
when not the center of attention / Interactions with others characterized by sexually seductive or provocative behavior / Rapidly shifting and
shallow expression of emotion / Uses physical appearance to draw attention to self / Has a style of speech that is impressionistic and lacking in
detail / Theatrica-exaggerated expression of emotion / Suggestible or easily influenced /Considers relationships more intimate than they
actually are. Stats- Originally ‘hysterical PD’ / Controversial: gender-bias, the ‘diva’ / Sorokowski, 2016: Online selfie posting predicted histrionic
traits in men, but not women, even though women posted more selfies overall. The Disorders: Cluster C Avoidant: social inhibition, feelings of
inadequacy, hypersensitivity to negative evaluation. Dependent: submissive and clinging behavior, excessive need to be cared for by others.
Obsessive-Compulsive: preoccupation with orderliness, perfectionism and control at the expense of spontaneity, flexibility and enjoyment.
Avoidant PD - Four or more: Avoids occupational activities that include interpersonal contact because of risk of criticism / Is unwilling to get
involved with people unless certain of being liked / Shows restraint within intimate relationships because of fear of being shamed / Is
preoccupied with being criticized or rejected / Views self as socially inept, personally unappealing, or inferior to others / Is unusually reluctant
to take personal risks or to engage in new activities because they may be embarrassing. Prevalence - Like social phobia, but social phobics
recognize that belief is irrational / Up to half of people with an anxiety disorder may have avoidant pd. Dependent PD - Five or more: Has
difficulty making everyday decisions without excessive advice and reassurance / Needs others to assume responsibility for major areas of life /
Has difficulty expressing disagreement with others because of fears of loss of support / Has difficulty initiating projects or doing things on
his/her own / Goes to excessive lengths to obtain nurturance, to the point of volunteering to do unpleasant things / Feels uncomfortable or
helpless when alone because of fears of being unable to take care of him/herself / Urgently seeks a new relationship if one ends / Is
unrealistically preoccupied with fears of being left to take care of him/herself. Obsessive-compulsive PD - Four or more: Preoccupied with
details, rules, lists, order, organization, or schedules to the extent that the point of the activity is lost / Shows perfectionism that interferes with
task completion / Is excessively devoted to work to the exclusion of other activities / Is over-conscientious, scrupulous, and inflexible about
morality, law, ethics and values. / Is unable to discard worn-out or worthless objects / Is reluctant to delegate tasks to others unless they
submit to exactly his or her way of doing things / Adopts a miserly spending style towards self and others / Shows rigidity and stubbornness.
Prevalence - Overlaps with OCD, but people with OCPD may take pleasure/pride in their compulsions / OCD, especially the obsessive symptom
domain, considered the extreme end of OCPD traits / More frequent in males. / 1% of population, 10% of psychiatric outpatients / OCPD
individuals demonstrated more accurate visual performance than non-OCPD controls (Ansari 2016) / In anorexics, OCPD (but not OCD)
positively associated w compulsive exercise; perfectionism. / Are PDs a real thing? - PDs as a diathesis (vulnerability), not disorder: Too much
overlap between PDs / arbitrary distinction between normal/abnormal / poor reliability= ebb and flow of expression of abnormal features / PDNOS too often used / Lots and lots of comorbidity.
Substance Use Disorders : Overview - DSM-5 Criteria Prevalence and Demographic Statistics: Gender and Age - Connection to PTSD. Theories of
Addiction / Motivation & Change Models of treatment: Alcoholics Anonymous, Harm Reduction, Relapse Prevention, Integrated Treatment.
DSM5: Substance (and Alcohol) Use Disorder A. Problematic pattern of alcohol/substance use leading to clinically significant impairment or
distress, as manifested by at least 2+ of the following, occurring within a 12-month period: Alcohol/substance is often taken in larger
amounts/for longer period than intended. -- Persistent desire or unsuccessful efforts to cut down or control use. --Great deal of time spent in
activities to obtain, use, or recover from alcohol/substance -- Craving, or a strong desire or urge to use alcohol/substance. -- Recurrent
alcohol/substance use resulting in failure to fulfill major role obligations at work, school, or home. -- Continued alcohol/substance use despite
persistent / recurrent social/interpersonal problems caused or exacerbated by the effects of alcohol/substance. --Important social,
occupational, or recreational activities are given up. -- Recurrent alcohol/substance use in situations in which it is physically hazardous. -Alcohol/substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or
exacerbated by alcohol. -- Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol/substance to
achieve intoxication or desired effect. -- A markedly diminished effect with continued use of the same amount of alcohol/substance. -Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome: (typically includes anxiety, shakiness, sweating,
vomiting, fast heart rate, and a mild fever. -- More severe symptoms may include seizures, seeing or hearing things that others do not,
and delirium tremens.) --Alcohol/substance (or another closely related substance, such as a benzodiazepine) is taken to relieve or avoid
withdrawal symptoms. Prevalence and Demographics of SUDs - Adult lifetime prevalence for drug use disorders (excluding alcohol) is 6.2% /
Marijuana most widely used drug followed by non-medical opiate use -- Tobacco used by 66.9 million people (55.2 million smoke cigarettes)
and rates are decreasing among teens- 4.9% in 2014 vs. 13% in 2002 smoked cigarettes. --Race/ethnicity, ordered of most to least prevalent:
Native American, Hispanic, White, African American, Asian --Estimates of overall costs of substance abuse in the US exceed $600 billion
annually -- Lifetime prevalence for alcohol use disorder is about 15%, --More prevalent among men (12.4%) vs. women (4.9%) -- 1/3 of young
adults (18-25 yrs) binge and 10% are heavy alcohol users. Gender Differences with SUDS - Women start substance use later -- Progression for
alcohol use disorder in women is faster because: Stomach enzyme to metabolize alcohol is more active in men -- Women tend to weigh less
and have a higher proportion of body fat, so the “tank” into which alcohol is added is smaller, absorbs a greater proportion of alcohol -- Women
are more likely to have partner with SUD -- Higher rates of comorbid diagnoses in women -- Women more likely to abuse prescription drugs
than other substances -- Women have higher mortality rate for SUDs -- Gender minority youth had increased odds of SUD, associated w
victimization (same trend w LGB youth). Gender Differences in Substance Use Across the Lifespan: Equal in men and women (or slightly higher
in women ) during adolescence, high in women age 12-17 and higher in men age 18 and older. Connection Between PTSD & Addictions - 80-
95% of those in treatment for an addiction have a trauma history (Brown et al., 2003) / PTSD is 3X more common in those with addictions than
general population / Untreated PTSD symptoms lead to increased relapse, with a faster return to drinking after treatment / Women with
histories of child sexual abuse (CSA) are significantly more likely than women without CSA to report SUDs / May be way of coping with trauma
& associated affect / Substance use prevents healing from PTSD. Overdose/Drug poisoning - 95% of all deaths from overdose involve more than
one substance / Opioids and benzodiazepines are a common combination. / In 2012: 58% of opioid analgesic-involved deaths involved
benzodiazepines / 40% of heroin-involved deaths involved benzodiazepines / Four in ten involve alcohol. Moral Theory of Addiction: Prevalent
during 18th & 19th centuries/ Addiction as function of weak moral character, lack of will power, personal choice / Person viewed as “morally
corrupt” if couldn’t control alcohol use / Fueled movement that led to Prohibition in 1919 / Moral deficiencies are what lead to substance use
in the first place / Desire to escape pain, seek pleasure, compensate for feelings of inadequacy. Washton Disease Model : Addiction as
”complex brain disease”: Certain individuals are predisposed to develop addiction based on biological response to certain substances -Continuing to misuse substances results in biochemical changes to brain, leading to dysregulation & loss of control over substance use -Reward system in brain changes & leads to increased vulnerability to relapse -- Shifted focus away from “moral deviance” -- Shame reducing or
enabling? Principles of disease model: Once addicted, person can never return to “controlled use” & must be abstinent from all substances -Use of one substance (may not be drug of choice) can lead to relapse on drug of choice -- Recovery is lifelong process. Genetic Addiction
Models (DiClemente): Genetic/physiological: No single gene responsible, thought to be multiple genes interacting in complex system / Most
research has been done using alcohol use disorders / Increased risk ratio as number of alcohol-dependent relatives increases / Contributed to
development of disease model of addiction. Social Learning/
Behavioral Models Behavioral reinforcement/Conditioning: Physiological responses to use such as tolerance & withdrawal reinforce substance
use. Coping/social learning: Addiction can be means for managing distress & coping / Is influenced by expectations of relief / Learning from
others (i.e. parents) to use as a means of self-regulation / Drug preference more likely due to availability & affordability of a certain substance.
Self-Medication Hypothesis - Self-medication hypothesis incorporates cog-behavioral, biological, psychodynamic principles: Relieve underlying
subjective states of distress / Maladaptive coping strategy / Addiction cannot be resolved unless individual addresses personal
meaning/function of use (i.e., conflict, ego deficits, avoidance). -- Opiates: numbing/calming -- Central Nervous System depressants: soften rigid
defenses to relieve isolation/anxiety -- Stimulants: counteract depression/emptiness. Biopsychosocial Model - No single factor can fully explain
development & maintenance of addictions / Model focuses on risk factors & protective factors, and how they interact. Risk factors in the biopsycho-social model: Personality traits: Aggressive behavior in the 1st grade found to predict heavy alcohol use in late adolescence (Kellam et
al., 1983). Psychopathology: 2 most common disorders identified repeatedly: depression and antisocial personality / Chicken or egg? / Many
patients entering drug abuse treatment facilities suffer from co-occurring psychiatric disorders / Externalizing disorders. Peer/Familial factors:
Negative role models, Parental attitudes toward use, Among older adolescents, peers have a greater effect than parents on drug use. Social
stress: Marginalization, poverty, etc. Physiology: High tolerance. Motivation & Choice: the normative course- Initial pleasure gives stimuli
reward value >Stimuli-related info becomes increasingly salient >After several administrations, habituation sets in > Motivation decreases for
stimuli, as does use. Example: with repeated administration of apples, stimuli related to apples becomes less salient and you are LESS
motivated to eat more apples. / In substance use disorders, all substances increase dopamine in the brain. This prevents the normal habituation
of drug-related stimuli from taking place. Motivation to use increases instead of decreasing. With repeated administration you are MORE
motivated to use Drugs. Why continue if it is no longer fun? Liking something and wanting it are distinct experiences: “Liking” habituates and
decreases after repeated administration, but “wanting” does not. Thus, SUDs are disorders of motivation: inability to inhibit
motivation/incentive salience of drug/substance. Treatment models: Alcoholics Anonymous: The Twelve Steps - We admit that we were
powerless over alcohol—that our lives had become unmanageable./ Came to believe that a power greater than ourselves could restore us to
sanity. / Made a decision to turn our will and our lives over to God as we understood Him. / Made a searching and fearless moral inventory of
ourselves. / Admitted to God, ourselves and another human being the nature of our wrongs. / Were entirely ready to have God remove all
these defects of character. / Humbly asked him to remove our shortcomings. / Made a list of all persons we had harmed, and became willing to
make amends to them. / Made direct amends to such people wherever possible, except when to do so would injure them or others. /
Continued to take personal inventory and when we were wrong promptly admitted it. / Sought through prayer and meditation to improve our
conscious contact with God. / Having a spiritual awakening as a result of these steps, we have tried to carry this message to other alcoholics.
AA: The research- No randomized studies of effectiveness -- No clear way of amassing data due to confidentiality. Pro- and cons of AA: Social
support, structure / Free and widely available / Can be disempowering, shaming / “Cold-turkey,” starting over / Pitfalls of ‘moral inventory’/
Religious undertones / Anonymity has led to abuse within the AA social group. The Harm Reduction Approach: Development of a hierarchy of
needs: Focus on current concerns, both short & long term goals / Way to engage client & keep them in treatment / What is the client’s sense of
what they need to address first? / Active drug users can and do participate in treatment / Success is related to self-efficacy & client’s belief that
they can change / Drug, set, & settings / Being sensitive to client’s unique relationship with each drug / Includes understanding mood states,
expectations, context of using / Any reduction in drug-related harm is a step in right direction. Principles of Harm Reduction: First, do no harm,
Drug addiction is a biopsychosocial phenomenon / Recognizes that drug use is initially adaptive/ There is no inevitable progression from use to
dependence /The right to sensitive treatment: Willing to work on clients’ concerns vs. own agenda. The Relapse Prevention Model: some
principles: Relapse is a common part of recovery -Most relapse within first 3-6 months. / Factors that support initial abstinence are different
from those that are needed to maintain recovery - Requires education about recovery, problem-solving skills, affect regulation skills. / Relapse
is a “process” - Goal is to increase awareness of small cues that are predictive of a relapse -- Slips or relapses can occur because of ambivalence
about sobriety. Relapse as a process: It is rare for just one factor to predict a relapse. / Potential triggers of relapses: Positive & negative moods
/ Environmental triggers / Poor coping & problem-solving skills / Sexual triggers / Unrealistic expectations, cognitive distortions / Post-acute
withdrawal symptoms / Conscious & unconscious motivation to continue using -- Shame, guilt, impact of early trauma. Myths about relapse:
Relapse starts once person starts using again. Fact: Using is seen as the end point of a relapse, not the beginning. --Relapses are unavoidable,
unpredictable, & appear out of nowhere without warning. Fact: Relapses occur in response to identifiable triggers -- Relapse = treatment
failure. Fact: Relapse is a common part of the recovery process -- Relapse erases all progress made so far. Fact: It takes most an avg. of 3-4
action attempts before successful remission. Integrated Treatment for Trauma and Addiction -The Seeking Safety model (Najavits, 2002): Goal=
Address substance use in context of past & current traumatic experience / Acknowledge current impact of trauma / Manual-guided, CBT-like,
mindfulness, etc. / 25 group sessions (can be used in any order & in 1:1 tx.) / Helps clients make connection between trauma experiences and
substance use / Emphasized throughout treatment / Also focus on relapse prevention skills / Learn how to cope without relying on substances
or risky behaviors.
NOTES : Men tend to get it earlier than women (late onset). Synaptic pruning - three waves of neuron growth, brain cleans up excess or
unnecessary connections/synapses so that the stronger synaptic connections are left and strengthened (more efficient). Irregular or prolonged
pruning can develop in the onset of psychosis in schizophrenia / Synaptic pruning: excessive in schizophrenia. / Dysregulation of dopamine parkinson’s(too little dopamine) and schizophrenia (when individuals with schizophrenia take anti psychotic medicine(block dopamine
receptors) they are left with motor functionings similar to a person with parkinson's disease). Schizophrenia has excess dopamine. DSM-4
(focused on the presence of a problematic way of thinking) - DSM-5(focused on adaptive failures in four areas) identity, empathy, Usually PD’s
ego-syntonic rather than ego-dystonic/ (depression vs. PD’s) - who you are and how you function, harder to separate disorder from identity . /
Psychoanalytic way to view personality : different defenses, people with PD’s engage in more primitive and immature defenses (highest
defense). /Sublimation - channeling distress or aggression into functionality / Psychodynamic - Internal relational schema - childhood actions/
experience ex. How to get attention / Cognitive-behavioral
12/10 - Charming - antisocial personality disorder, narcissistic personality disorder. BPD - distress act out, lifetime prevalence 1-2%, really high
rates if suicide, self injury. / Treatment regulating emotions -/ Inhibits emotional (imbalance for prefrontal and limbic activity)/ Emotions are
actually intense and hard to control. Histrionic PD - emotions look intense but they are actually shallow, express intense emotion for the sake
of attention. Considers relationships more intimate than reality. Narcissism vs Histrionic PD - desire admiration more than they want to be like
vs. want everyone to like them and love them (likeable at all times) notorious vs. sympathy. Cluster C : Avoidant personality has similar
presentation to social anxiety disorder . Obsessive compulsive disorder - need to control, more than one compulsion absolute need of control in
all aspects of their life . Avoidant PD - convinced of their own inferiority or internal problems (social phobia individuals can recognize their
beliefs are irrational) .Avoidant PD is more chronic and begins earlier, egodystonic (usually). Dependent PD - More likely to enter unhealthy or
toxic relationships. OCPD - overlap with OCD but OCPD is egosyntonic and take pride in their compulsion and behavior. Criticism between PD’s
- overlapping, distinctions seem less significant and arbitrary. / 95% of overdose more than one substance/ Familiar with risk factors.
Motivation - number of administrations, addiction differs because dopamine released by drugs or alcohol prevent a dip of interest and
abnormal motivation to continue number of administrations